""""nt.noI nutrit",n (PN) ref"", to the deli"ry of nutrien" into. centr.ll 0<
peripher.ll , .. in by an int ... >o ... ' (LV.) deli>ery 'ySlom thot i. """"time, .Iso c:dled hlp<nli;m<ntat;on. f'N i. odministcred either., . ",Ie ... rce of nutrit;oo 0<
to supple""'nt enter.ll feedings, .:nt<nJ nutrition refers to the deli>ery of nutrient>
through the gwroint.stinal _ t , either natu"dly or by u,ing feeding tuhe, that deli,'''' nutricn" into the """""'h. duodenum. Of jejunum. Deli>cring nut""n" by the e nter.ll routo i, I""fem-d to del i>eri ng n utrien" by the par< n", ... 1 route "he"",..,r possible bee.u"" when the g .. trointe"inol tr>ct is no< used. viII"", otrophy occur, . .00 the g .. trointc"inol tract', competcncy ot digesting.oo meubelizing nutrients in the future become. compromised.
In"""" in,unce,. it m.y no< be I""'iblo to mect J»tien'" toul nutritional ...-d, through either natu",1 mean< or odmini".ring gast"", docde ... 1. Of jejunal tube feedings, The"" J»ucn" ioclude those wbe canno< completely
w.oro
nutrients bee.u", of ,hort bewel .yndrorne. fOf in".~_ Not odmini"cring nutrient.sullic;"nt to """,t doily c.loric needs can Icod to h),poolbumill<mi • .oo ""sati""
nitrogen bal.~. ,,'h;"h can leod to loss of .kele .. 1 muscle ... . nd c""he,i., poor
"""nd he.ling. 000 diminished immunocompetence, Thu, the .. (»-ti<n" m>y require the deli,'ery of additional nut""n" p""'nte ... lly.
In 110m< i",""",es. (»-tien" ... unobk to ing ... or.b>ort> "ny nut""n" enter.llly.
n....
(»-t",n" mu .. h .. 'e their nutritionol require,""n" met <ompl",.ly through nutrien" deli,'ere<! by. p""'ntc",1 route. E. . . mp'" of poti.n" "'be " .... Id require thi, include those potien" "'00 h.ve g."roin""'in.1 fistul .. .00 int.stin,1 obstructi"",."rif'"
'0 1M Mli",,)'of
"Ulri,n19 into a c,nlral or puipMru(, ... in 17)' an I. V. <hli"",)'
'J'u","
CHAPTER 10 Parenteral Nutrition Therapy
Types of Parenteral Nutrition
PN
Jd"- ....
IIdmi",d ift<!ividuolly ift phat", .. " •• ",iftl ....pi< IKbnioq ....undn bmirur _ _ .. 'The f""""l1 - t 10 lid ... OR)' ~
"""lion ;,.
ba..d ""the indi,'idooaI patieno". caklolal<d "uid. .1t<1toI) ....
....a
<:&lone: "'1" ... In widrm .'it!J ttw.. ~ the pol .... '. optC.1;c mouI>oI .. n<e<h tIut <211all .... fIooid. cl«:tro/ylc ... utriML
....a
","""",,1riecI1 roqu'~"...,
I2Un;.,""""'"'" Lo ~ the _ ftutno;c.wly ....
',.1' ... 1*'""""'"'
ooIouOII po<>i ....f<lItIut .... irnl.
TOTAL PARENTERAL NUTRmON SOLUTIONS
MoM PN 0010",- " . . . . <M:f .JO doffcmol < ... ."... ,,,,,_,,. .-..
dectroiyo.., miL •
.-orimto. ....a "'""'""""'1.0.
The ...,.... oI."OIrr tIut >l1000101 to..<l<1iv<ftd .. ill> PN ... """ i. Of'P"I"ma<tly JO...J5
mLAa
por day" 1'loctroIY""moy include the foIloo.l"':
SoWum. .,,111. _ . -daily ... ' ... oI4()..SO ml'.q _ium. .,,,h • """"""".- .... ly ... , ... '" 01 JO..4O mEq ChIoriok •• ,j1ll • """"""".- .... Iy ... , ... '" 01 4()..SO ml'.q 1'IlospIooI<. "'i,h. _ n d < d da,ly '"'Iu, ... 0115-2' mmoI M"!! .... jum. ,.'i1l\ •
m:oon ....
noXd d .. ly '"'I.,; ... nt 0111-1 ~ mEq C.kium. .. ioh • """""""ndtd daily '""Iui ... nt012-'
ml'.q"MicrtHlutri,mu include vil.mln. and I ... "'i ... 1<. Tho vit.mi .. rotDpooit"'"
of typic.1 PN ""Iutioo. inc) ... the fnll"w;n,: I m& vitamin A (l'<1inol)
3 m& vitamin 8, (ohi.m;",,) 3.6 m& .itomin 8, (ribon"'ift)
I~"'l! v".mon 8, (lIi""in) 4 m5 viwnin 8, (pyrido.ino) 60 I'll ,'jWllln 8, (bootin)
4(X) ~I vi,omon 8. (folio Kid)
~ ~, oi'omon 8" (<:ObolanI,.) 100 "'I "i ... ,. C (-..toic ocid)
~ ~, .. wrun 0 (C1)eaIoifnol) 10 IU ' ... n E (,,",opI>c,oI)"
'" I.V. Therapy Demystified
PatienlS who ore "'" taking <:4".1 ""'ic""8"1 .. " (e.g .. warfarin lCoomodinl) l1IlIy be I""",ribed PN solu,ioo. <hat .1", coouin 1-4 mgld.y ';Wlli"
K,""
Trxe m'''''r.ll. that typically.re admi,ed to 1'1'1 ..,Io'ions include zinc. chromium. oopper.mang .... ,.,. and oom<ti ... lenium. Viwn,,,, and tire elements ore <=<nu.1 compone"" of PN soIu,;oo. bee""", ,hey en,ure ,hal mac"",uwn" .an be .... t>boliu-d .ppropriately."'"
Macron"trien" _ to I'N ",lu,ion. ioclude J>IlIIein. and carbohyd""e. and _;me. fat •. 1'1'1 ",IUlions <hat coo"," 1"""0; n. and carOOilyd""e. are ... time.
referred
to .,
l _in_! PN JOiu,imu Of oome<imes tolal parent ... 1 nu,nt;"" (TPN) ..,Iu.i""., f'>.,ic"" ,.,ho receive infu,iOlU of the 2-io_1 11'1'1 solu,ions require",,,,,Iemenllli J»«n'enl infu.ion. of fat emulsion. (see below). PN formul., that coolain .11 three e.",",ial mr"",utrienlS of proIein" <arboIlydnte._ and fats are
><>mel'me. referred to .. J_in_1 PH
wi.,i"",
()f """",ime. tolal nu.';'nt adm;'to .... (INA.).n..
following sec'''''' d=:ribe. TNA> in rno<e <lcla'!.n.e ...
nl of prole, .. and carbohldrate. in "ny 2_in_1 1PN fOfmul •• oan be highly y:lri.Me based 011 ,be individual paI;"n1'. c.kulaled nee<b ond moomolic"'''e. The mosI common carbohydrale ... "'" i. dexu,""". which can Clnge in
""Iu,ioo """""nU>lion< from S_70 percen'," Glycerol """",ime. i< .1"" ",cd . . . n addi'KlmI >OY"'" of oarbohyd ... in Tf'N ""Iu,;o.", ll'N ",IUlioru with. dex'""", cooc<nlnl';oo th., i. gre .. er than 10 percen' r.hould be infU>ed 'hrough 10enlnll ,'.,noo. >Cee ... i .. ,"
f'roIein i. provKled by admi.ing amino ""ids ,",'ith II>< ""Iu,;oo .. 'I'P"'.irru".ly 0,8 glkg per <by, The adml I"",,:ribed TI'N roocenlr.illiorr of proIein c.n "'1)'
coo.ider:ably depending 011 the pa'ien.-. metabolic >I ... ond .bility to metabolize protoin •. " For in5l:u>re. pali.",. with acu .. reml f.ilo", m.y DOl be able to rid themsel.e. of ,be nitrogen tha, i •• by_p<odoct of omino IOrid "", .. bolism.nd c.n become azotemic_ Therefore. Ihe>e p"';"n" t)pic.lly:ore p<e",ribed few.r omino
"",id. in their ll'N solution<,
ll'N oolotio", "'" d • ., yellow in wl".-, Boc.u", Tf'N solution. beeome u",lObl. when exJl"'S"'l to light and extre""" in tempe ... tu",. they are typic>.lly
>lored in. refriger.otor." II i. recom"",oo.d th .. ,be", b'g> be remo.ed fr<>m II><
r<Frige ... tOf I hour before they "'" hung so thot • cold ""Iut",n i. nOl info",d into the poti.nt,'" If a TPN lV, Ng i< hanging fOf mo<e tlwl 24 hours. it ,hould be changed bee,u", i, may become unst.ble""" Eoch bag of TPN >olu';on ,hould be ... mined closely before it i. hung f".-any evKlenre of precipitate".- partK:u1aie matter, If .ither of the>e i, I""",nt. ,be bag oJrould nOl be hunB and ,I>oold be ,,,,umed to the p/I"""""y. It i. possible that ll'N ..,Iution. c.n cOllt,"n precipit ... or patticulate matter th .. i. not .i<ibl., To I"","n' p .. ients from
~i,'ing infused precipi .. te Of partK:ulate mat .. r th.t can become emboli, ll'N ], V.
><tups .h""ld include . O,2_~m filter,'
HHi' I!.; m
~IO~~ ~~_.3~I~HF 1l
..,'H!i.'WrU' ~
5"t fc.r
M • • •~. a- a i! 1 P' n. ~ ~ t n
%,..
~1~t~· lij if ~.n ;; 'l
....::-<'
~.i
Q, 3 ] ~oil
~ ~. l !:'
. ,,~,
~-p=dE;-'
~ ~-- -;$"
C£ ~
~"5
Zi~ ~~~q lf~ [;; !1~'lh";'11 =i
~~", l'~ P' i' f' ;ii"!}' . " ~.! - ~ LHt <!"'"H'~ 'f"'~'l ~ Z i!.. I
~ 0if '" ~~; s.. it::,!} f ~ ,<.i. ~.§I~j !i~l
I!."it _ ~ If
VI~iti'~II'::li:lu~a-1 :.~llniii,i if
- i~ lH . I " •
!.Ii'l<'" d .. ~ ~!!:!~ i'~ ~!;_[ - ' " j ' 'H·q,f'i~"I~ -IO-i:! ... . '" I ! . !l ,
~•
;'111 J tiP
~'" - i' ~l~!t",..~--~ ~i!:j ~~ i~ i!:;C _ . " -
~ 1!~!" ' " r " ;'j; [ "-'" ' I'''l ,~. " _ , S ~ "'"
"l
~11
1; ~• - Z
"_lol'lll' - 'I' ~ -r .. ... !!
~•
I "' ~ I!- . ;:~ ~(:]. ~i~l~~~-~~~i .,., _~!!f"'l '?' -It! i~lf ! .,., "1i-~,,"5 ~h -.,. ~ " ~ f ~ "'P'I ~lliti! . . ,r.... · ·II:;il -H1
10i "f i ,. l;:: H "
~"-
0- ~ ~ ~ ~ f =8 ifF
#e- i" I - , diW JiH " ~J
~; - "ii<fa!fl:.--!i. if
a~ ~ i'I" ~t" '" u~!~[.n [-5
"~"'f-".m§ · £.3~~-i ;:.~.
ai!~,-l
~~;~'i'~i~
- =il'~~O l"
;<if H~-IJ ;~-'rl .!fhii .... rol , n
~ ~n - . ,
. ~ ~• •
Ii=>
II. -
~- - ~Hj~1 l~ii;!' ~ ~
~"~'I-j'
~ ~l~<
-'' "
~~ - • ff~"i. il ~~
~ ~. ~ - ~ y ~ ~ ~ ~
~~a-~I ~t~~i!!~: f
II~l'-~~i 'Id '~o· !a-~n ',d' lib. I .. " i.f, I ~
'" I.V. Therapy Demystified
Patien .. with. history of .Ilergie> to
.u.
Of to .. m""", or >o)'bean prooocu or oil. should 00< be pr05<ribed IV~"Es,"''' So .... ",,'ients without a kooo.'o .Ilo~y to any of !he", ooocth<],e,. moy . . hibi, lUI immuooglobuhn E (lgEJ.-mcdiated .nergic re""'ioo.n.e",
may be . . hibitod by fl"~i"g,un,.,.,;.
(i .• " hive.), and '",hing.particularly of ,be pal"" of tbe moo. or